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Health Insurance Claims Chapter 3

The intent of managed health care was to... replace fee-for-service plans with affordable, quality care to consumers
Which term best describes those who receive managed health care plan services? enrollees
What was created in 1929? the first managed care program
Which was the first nationally recognized health maintenance organization? Kaiser Permanente
During the 1960's debates on how to improve the health care delivery system ensued because: health care costs had dramatically increased
Which legislative provision of TEFRA allows federally qualified HMOs to provide covered services under a rish contract? medicare risk programs
The medical center received a $100,000 capitation payment in January to cover the health care costs of 150 managed care enrollees. By the following January, $80,000had been expanded to cover services provided. The remaining $20,000 is: retained by the Medical Center as profit
Which is a nonprofit organization that contracts with and acquires the clinical and business assets of physician practices? medical foundation
Which is responsible for supervising and coordinating health care services for enrollees? primary care provider
Which term describes requirements created by accreditation organizations? standards
A voluntary process that a health care facility or organization undergoes to demonstrate that is has met standards beyond those required by law accreditation
Provider accepts preestablished payments for providing health care services to enrollees over a period of time (usually one year) capitation
Submits written confirmations, authorizing treatment, to the provider case manager
A review for medical necessity of tests and procedures ordered during an inpatient hospitalization concurrent review
Include many choices that provide individuals with an incentive to control the costs of health benefits and health care consumer-directed health plans (CDHPs)
also called "covered lives"; employees and dependents who join a managed care plan; known as beneficiaries in private insurance plans enrollees
A managed care plan that provides benefits to subscribers if they receive services from network providers exclusive provider organization (EPO)
Reimbursement methodology that increases payment if the health care service fees increase, if multiple units of service are provided, or if more expensive services are provided instead of less expensive services. fee-for-service
Primary care provider for essential health care services at the lowest possible cost, avoiding nonessential care, and referring patients to specialists gatekeeper
Participants enroll in a relatively inexpensive high-deductible insurance plan, a tax deductible savings account is opened to cover current and future medical expenses. Money deposited is tax-deferred. Unused balances "roll-over" from year to year. health savings account (HSA)
Contracted health care services are provided to subscribers by two or more physician multi-specialty group practices network model HMO
A physician or health care facility under contract to the managed care plan. network provider
Include payments made directly or indirectly to health care providers to serve as encouragement to reduce or limit services physcian incentives
Plan in which patients have freedom to use the HMO panal of providers or to self-refer to non-HMO providers. point-of-service plans (POS)
A network of physicians and hospitals that have joined together to contract with insurance companies, employers, or other organizations to provide health care to subscribers for a discounted fee preferred provider organization (PPO)
Is responsible for supervising and coordinating health care services for enrollees and approves referrals to specialists and inpatient hospital admissions primary care providers
Reviewing appropriateness and necessity of care provided to patients prior to administration of care prospective review
Reviewing appropriateness and necessity of care provided to patients after the administration of care retrospective review
When a second physician is asked to evaluate the necessity of surgery and recommend the most economic, appropriate facility in which to perform the surgery second surgical opinion
Person in whose name the insurance policy is issued subscriber (policyholder)
Method of controlling health care costs and quality of care by reviewing the appropriateness and necessithy of care provided to patients prior to the administration of care utilization management (utilization review)
Employees and dependents who join a managed care plan are called: enrollees
Which act of legislation permitted large employers to self-insure employee healthcare benefits ERISA
If a physician provides services that cost less than the managed care capitation amount, the physician will: make a profit
The primary care provider is responsible for: supervising and coordinating health care services for enrollees
Which is the method of controlling health care costs and quality of care by reviewing the appropriateness and necessity of care provided to patients? utilization management
Accreditation is a _________ process that a healthcare facility can undergo to show that standards are being met: voluntary
Which type of health care plan funds health care expenses by insurance coverage and allows the individual to select one of each type of provider to create a personalized network? customized sub-capitation plan
Which type of consumer-directed health plan carries the stipulation that any funds unused will be lost health care reimbursement account
Which is assessed by the National Committee for Quality Assurance? managed care plans
A case manager is responsible for: oversee the health services provided to enrollees
The event directly responsible for the dramatic increase in U.S. health care costs was the: implementation of Medicare and Medicaid
Which was created to provide standards to assess managed care systems in terms of indicators such as memberships, utilization of services, quality, and access? HEDIS
Which act of legislation provided states with the flexibility to establish HMOs for Medicare and Medicaid programs? OBRA
Which would likely be subject to a managed care plan quality review? results of patient satisfaction surveys
The Quality Improvement System for Managed Care (QISMC) was established by: Medicare
Arranging for a patient's transfer to a rehabilitation facility is an example of: discharge planning
Administrative services performed on behalf of a self-insured managed care company can be outsourced to a : third party administrator
Before a patient schedules elective surgery, many managed care plans require a: second surgical opinion
A "health delivery network" is another name for an: integrated delivery system (IDS)
When each provider is paid a fixed amount per month to provide only the care that an individual needs fro that provider sub-capitation payment
A review for medical necessity of inpatient care prior to the patient's admission preadmission certification
This prevents providers from discussing all treatment options with patient's, whether or not the plan would provide reimbursement for service gag clause
This program includes activities that assess the quality of care provided in a helath care setting quality assurance program
This contains data regarding a managed care plan's quality, utilization, customer satisfaction, administrative effectiveness, financial stability, and cost control report card
Offered by a single insurance plan or as a joint venture among two or more insurance carriers, provides subscribers or employees with a choice of HMO, PPO, or traditional health insurance plans triple option plan
Cafeteria plan is also referred to as: flexible benefit plan
Created by: kduvall20